Tuesday, February 28, 2017

Sean
MacStiofain said “most revolutions are caused… by the stupidity and brutality
of governments.” Regulation without legitimacy, predictability and fairness always
leads to backlash instead of compliance.If something is not done to stop MACRA implementation, more physicians
will opt-out of Medicare and Medicaid than is fathomable.Once DRexit begins, there will be no turning
back.

The
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is destructive to the
physician patient relationship because it prevents physicians from prioritizing
patient care.MACRA supporters like to point
out this legislation was passed with bipartisan support; in reality, it was
passed simultaneously with repeal of the Sustainable Growth Rate Formula. The SGR
was holding billions hostage and lawmakers had a gun to their head, leaving
them no other choice. There is nothing bipartisan about that.

The
Sustainable Growth Rate Formula was enacted through the Balanced Budget Act of
1997 and was designed by lawmakers to control Medicare expenditures. The SGR
formula limited the annual increase in cost per Medicare beneficiary to the
growth of the national economy.Under
the SGR formula, if overall physician costs exceeded target expenditures, a reduction
in payments would be triggered.Expenditures continued to climb, so Congress stepped in 17 times with
short-term legislation (referred to as “doc fix”) to avert the payment
reduction since 2002.

These
patches kept increases in physician payments below inflation which ultimately
resulted in a huge discrepancy between the actual level of Medicare
physician-related spending and the target in the SGR formula. In 2015, if
Congress did not act by March 31, payments to Medicare physicians would have
been reduced by 21.2 percent.

Enter
stage left, MACRA, known as the Permanent Doc Fix, which was passed concurrently
with the Sustainable Growth Rate Formula repeal legislation.This was the original repeal and replace.MACRA established yet another new (and
untested) method by which to pay doctors. MACRA is the largest scale reform on the
American health care system since the Affordable Care Act in 2010 and the jury
is still out how great (or not) that system is working for the American
people.

Under
MACRA, the Secretary of the Department of Health and Human Services was tasked
with implementation of a Merit Based Incentive (MIP) program which consolidated
three useless incentive programs into one big colossal unworkable program for
eligible physicians everywhere. The legislation also allows for Advanced
Alternative Payment Models (APM), which shockingly, are not actually saving
money on care.

Even
better, MACRA related regulations also addressed incentives for use of health
IT by physicians and other care providers.Similar in scope to the Meaningful Use (aka Meaningless Abuse) Program
except, now on steroids.The Government
Accountability Office in partnership with the DHHS have been assisting with the
implementation of electronic health records (EHR) nationwide, while at the same
time comparing and selecting programs for providers.

So
to recap, Congress has been working on a “doc fix” system in conjunction with
every lobby possible on the planet EXCEPT that of Practicing Physicians since
1997.They “repealed and replaced” SGR (first
disaster) with the atrocity known as MACRA, which will end in a mass DRexit.They are rapidly moving ahead with
non-evidence based payment methods intended to decrease costs, yet are highly
unlikely to be successful based on recent studies.On top of all that, they are selecting computer
systems for physicians which incentivize computer data entry while discouraging
the placement of hands on patients.Did
I miss anything?

Recent
studies show physicians spend twice as much time on technology than we do with
patients.Maybe with full MACRA
implementation, we can be retrained as data entry clerks to treat conditions
instead of people.Imagine if we just
called in prescriptions for hypertension, diabetes, or even started
chemotherapy regimens without seeing patients at all?MACRA pays us more for “doing less,” so now
we can practice “drive-by medicine.”I
wonder if health outcomes will improve and mortality will be lower when
compared with “drive-by shootings.”

Controlling
costs involves four major pillars of change to our healthcare system, about
which I have been writing for some time.Listening to a talk given recently by the executive director for the
Association of Independent Doctors, Marni Jameson, helped focus the strategy.The first cost control pillar is to educate
patients and lawmakers as to how consolidations of hospitals and medical
practices raise costs, reduce quality, decrease access, eliminate jobs, and
result in unnecessary testing and procedures. The second pillar is to increase
price transparency, so consumers can compare costs and choose the most
affordable option. The third pillar is eliminating the onerous ‘facility fee’ to
bring payments of hospital-employed doctors in line with the lower payments to
independent doctors for the same care.The
final pillar is ensuring hospital profits are taxed equally across-the-board,
regardless of whether they are non-profit or for profit institutions.

In
the next four posts, I will cover these issues in more detail as each deserves
its own separate discussion.It will be
an interesting mathematical exercise to calculate the forecasted cost savings
of these four interventions alone. If
you are reading this post, you have skin in the healthcare game, whether as physicians,
lawmakers, economists, hospital administrators, government, or IT experts alike.As I have said before, we will ALL be
patients eventually.

Tuesday, February 21, 2017

As physicians ready themselves for the future of medicine under onerous MACRA regulations, it seems appropriate to glance into the future and visualize the medical utopia anticipated by so many.Value-based care, determined by statistical analysis, is going to replace fee for service.

Six months ago, I received my first set of statistics from a state Medicaid plan and was told my ER utilization numbers were on the higher end compared to most practices in the region.This was perplexing as my patients tend to avoid ER visits at all costs and can be found milling about in my parking lot at 7am on Mondays with their sick children waiting for my office to open.

I requested more detailed reports on ER utilization and was given a 20 page list with codes that needed to be hand matched to patient names.Being a committed and diligent physician, I spent a random Saturday evening matching up 420 names to individual 15-digit codes after putting my children to bed.Of my top 20 utilizers, only 8 were actually patients.The remaining 12 had been “on my panel list” during the reporting period but had never set foot in my office.Of the top 100 utilizers, only 42 were patients.In the interest of accuracy, I requested they re-run the numbers using my patients only.Mr. IT informed me the inaccurate panel would make no difference.He might have failed statistics in college but who is keeping track.

I have spent 6 months on what I call obsessive-compulsive panel management (OCPM.)My Medicaid panel has been closed for the last 9 months in anticipation of opting out by 2019.OCPM meant 150 non-patients on my panel needed to be reassigned to primary care physicians who had space to accept them. Apparently, no physicians have requested this before, the insurance administrators were stumped as was the state department of health.After more than 200 hours spent on this process (instead of seeing patients), I have whittled down the list to a comfortable 316 as of January 1st 2017.

Last week, I received the second round of numbers, covering the period ending in the previous year.Panel management was going on during this period but was by no means complete, so it is still not an entirely accurate reflection of my “quality”.Mr. IT could not believe the difference in just one reporting period!I would argue the accuracy of the panel had an impact on those statistics, but what do I know about such things?

He was excited that we have not admitted a single asthmatic patient in the entire reporting period, which is obscenely lower than the nearest practice in the region and the lowest in the state.I almost told him we have not admitted an asthmatic patient in more than 15 years but thought he might have a heart attack.

Asthma admits will be metric #1 to demonstrate my high quality.My ER utilization numbers are below the local region and on par with state numbers. I suspect accuracy is still not quite where it needs to be but have no interest in spending a free Saturday night matching up names and numbers manually to figure this out.At least we are trending in the right direction.There is metric #2.

The search began for metric #3.My frequency of ordering imaging studies (excluding X-rays) was above average.Interesting, since I ordered only one test on a child with kidney stones last year.After inquiring if the data reflected all scans done on patients from my panel or the just studies ordered by me personally, Mr. IT did not know.He is working on it and will get back to me in a month or so, when he figures out how to do that sort of thing.He could tell me there was a disproportionate number of echocardiograms ordered.

Armed with that information, I could hazard a guess where my ‘quality problem’ lies; I have a largepopulation of children with cyanotic congenital heart disease, referred to me by a certain pediatric cardiac surgeon who thinks I provide quality primary care.Many of these children get echocardiograms before and after cardiac surgery, other procedures, or whenever deemed clinically necessary by the specialist.

Why do we have to employ an IT guy to give me information I already know?Why is the government paying him to do something I can do in my head?Why am I being penalized for a specialist ordering necessary imaging studies on pediatric heart patients?How does this demonstrate quality?

The search for Metric #3 continued. I have many families who are vaccine hesitant or non vaccinating and do not have the heart to turn their children away.Vaccination refusal is properly documented in the chart but the world of statistics does not account for these subtle nuances. There are companies emerging who can look at coding and catch specific words or phrases which help show quality.

While I have poorer numbers on percentage of immunized children, it turns out I had a perfect score on my mammogram recommendations. What mammogram recommendations?Last year, I evaluated a parent having an asthma exacerbation and while I wrote her prescriptions, we discussed her family history of breast cancer and the need to schedule a mammogram.My rate is at 100% because she is the only patient last year I evaluated who falls into this category and I happened to document the preventive recommendation purely by coincidence.Bring on Metric #3.

MACRA lets physicians pick and choose which metrics are evaluated for “quality.”This pediatrician is wholly committed to tracking mammogram recommendations at all applicable patient encounters in the future to demonstrate the highest quality patient care I am capable of providing.I read a recent blog post from a cardiologist who might track how often he orders imaging for back pain, since he had a 100% score in that particular category.

Imagine what quality metrics the pediatric cardiac surgeon is going to track.He would do well to collect statistics on how often he images patients for appendicitis because it is likely a rare occurrence.Things are really looking up for the use of data and technology in healthcare. Costs are likely to keep rising with everyone scoring in the 99th% percentile once they figure out how to game the system.But we certainly cannot stand in the way of science or progress now can we?

Tuesday, February 14, 2017

In the past few weeks, we have lost two female physician
colleagues tragically to suicide, a pediatrician and psychiatrist. In the general population, males take their
lives at four times the rate of
females.However, for physicians
specifically, the suicide rate is evenly distributed between genders; making
our occupation the one with the highest relative risk for women to die by
suicide.This is what I wish would
change about being a female physician; we must stop losing our own. We need to support each other,
love one another, and face our challenges together.

Fifteen
years ago, a surgeon called me in to evaluate a child with 3 days of fever,
abdominal pain, and vomiting.Her initial
white blood cell count had been 36,000, but she had been discharged home from
the ER with a diagnosis of viral gastroenteritis.Two days later, she returned with lethargy, continued
symptoms and a white blood count on admission of 32,000.The surgeon sought my input before taking her
to the operating room.

Tiffany
was 12 years old the first time I walked into her hospital room.Her mother was sitting next to her daughter on
the bed quietly stroking her hair.Tiffany
had poor color, delayed capillary refill, and was ill to the extent she could
not localize pain to her abdomen.Her
vital signs revealed tachycardia, lower than normal respiratory rate of 6,
hypotension, and fever.She needed
fluids, antibiotics, and pressors for impending septic shock.After I stepped out of the room to write orders,
she coded within minutes.Anesthesia
managed her airway and I straddled her tiny body while performing chest
compressions.Following a lengthy
resuscitation, she stabilized.

Later
that afternoon, the surgeon performed an appendectomy which included removal of
30cm of necrotic bowel, giving her the best possible chance for survival.Remarkably, she pulled through and recovered.She needed a primary care provider after
discharge from the hospital; a job I readily accepted.She informed me at the ripe old age of 14, she
was going to cut patients open and save their lives.She studied hard and began college classes as
a junior in high school. She shadowed me
countless times in my office; her enthusiasm for medicine was infectious. Her
commitment to a surgical career was unwavering.

We remained
in close touch after she left for college.She lost her father to a heart attack during her senior year.As an only child, her mother and best friend
were her strongest sources of support. Whenever home on break, she would stop
by to update me on her life and see patients with me.She
graduated from college with honors and was accepted into the medical school of
her choice.

Tiffany
was born to be a healer; she had a laser-like focus about her future plans. During her fourth year of medical school, her
best friend was killed by a drunk driver on a busy freeway.Tiffany was devastated beyond belief.Seeing her at the funeral, I knew something
was terribly wrong.She looked pale,
thin, and seemed despondent.Her mother
recognized her sadness and thought I could help.

Tiffany
was reluctant, but I insisted on going for a walk after the funeral.It was a rare sunny day and we ambled down
the forest path in silence for a good while before she shared her
thoughts.In her final year of medical
school, she felt like her world was literally falling apart.She was lost and uncertain of what she wanted
out of life.She could not eat, sleep,
or find the joy she once had.I listened
for a long time, before carefully formulating my response.

I reminded
her of the day a resilient 12 year old girl coded right before my very eyes, yet
stubbornly refused to die.“You survived
for a reason.Only you can decide for
what purpose you were given a second chance. Find something you are passionate
about.Do it for your mother, your father,
and your best friend; but, most importantly, do it for yourself.Being a physician is challenging at best and unbearable
at worst.You must find a way to
celebrate your successes, grieve your losses, accept the things that cannot be
changed, and embrace relentless uncertainty, or you will not be able to thrive.”

Six
months ago, she entered her third year of a competitive surgical residency on
the opposite coast.We remained in touch
but with each passing year, she has seemed more distant.There is a season for everything, and maybe
we have had ours.Then a month ago, I
received a letter in the mail and recognized her handwriting:

“Residency
has dimmed my love for medicine.There
are days I am thrilled to walk through those hospital doors and days when my
heart is filled with dread.Life is too
short for regrets, so I have decided to take a leave of absence and discover
where my heart truly lies.Thank you for
never giving up on me.

The last
time we saw each other, I was contemplating taking my own life.I could not face you knowing what was in my head
and my heart.You were right to be
unrelentingly persistent.Your reminder that
I almost died, yet survived against all odds, was the one thing I needed to reflect
upon and remember. Fifteen years ago, you
could have given up, walked away, and not given me that second chance.You refused to let me die.I do hold the power to direct my own life.Thank you for saving me twice.”

The
journey to becoming a physician is fraught with peril.We spend years acquiring the expertise to comfort
and heal others, yet those skills are attained at a great personal cost to
women in particular.Among female
physicians, the relative risk of suicide is 2.3 timesgreater than the general female
population. Each
and every tragic loss of a female colleague should be honored as if we lost a
part of ourselves.Their struggles must become
ours; their survival is imperative for us all. If you are struggling, please
know, we are here, we are listening, and we care.

#WomenDocsInspire

This essay is dedicated to every
female physician, resident, or medical student who has considered suicide or taken
their own life.May they find peace and
comfort and may we find a way to reach out to one another when we find
ourselves in need of support.

Friday, February 10, 2017

The market for medical tourism grows as Americans
increasingly seek medical care outside of the United States and pay cash for
services.Patients know they can obtain adequate
quality care in Mexico for out of pocket costs far lower than their insurance
plans with high deductibles would cover.Posting basic outpatient visit and simple procedure prices could benefit
our independent practices in the same way.The only thing worse than not having health insurance, is having coverage
be so expensive you cannot afford to utilize it when necessary.It is like sleeping next to a chocolate cake every
night while on a diet.

Mexico lags behind
most Organization for Economic Co-operation and Development (OECD) countries in
health status; however, they are the best in one significant
category.They have the lowest healthcare
expenditures of all the OECD countries, making visitation of the free-market
medicine “concept” worthwhile. A
majority of healthcare in Mexico
is provided via private entities or private physicians. The private
organizations operate entirely on a free-market system, less than 10% of
Mexicans have health insurance, so most pay “out of pocket.”

My family spent a week in Mexico over Christmas and on
the day we were due to fly home, my youngest son developed a very high
fever.Fever reducers were administered and
all was well until he vomited all over himself, his blankie, and the ground at
the resort entrance.By the time we
arrived at the airport, he did appear a bit limp and lethargic.“Is he sick?” the ticket agent asked.“Not really,” I lied.“Does he have a fever?” she asked.“Not at this time,” I responded.“You must be cleared by the physician at the
airport before I issue your boarding passes”, she stated.“Does it help that I am a pediatrician?”
Nope.

Resigned to my fate, I waited in a quiet corner until
a young physician and his medical assistant approached.He introduced himself and asked me a few
questions before suggesting an anti-emetic injection prior to the flight.Needing to obtain a weight on my son, we followed
him to the clinic, which looked like a mini-ER including two fully stocked treatment
beds yet surprisingly no additional staff.The physician gave him a quick shot on the rear (Metoclopramide), filled
out some PAPER-work, and handed me my copy of the encounter including an
itemized bill:300 pesos for the visit
and 100 for the injection.I paid him in
cash, approximately $20 USD.

As he escorted us back to the airport waiting area, we
shared some frustrations about our respective careers.He told me about a young child from the day
before who was severely dehydrated to the extent he required significant fluid
resuscitation.Due to the child’s precarious
hydration status, an IV had to be placed in his jugular in order to
successfully deliver fluids.This young
general practice doctor had a wide repertoire of skills, despite access to little
in the way of resources.

Which brings me to the point, I need a light, a
stethoscope, and a pen to heal and comfort human beings; the rest is basically nonessential.This Mexican physician and I fundamentally do
the same thing every day; except he has no receptionist, no billing personnel, no
manager, no administrator, no care coordinator, and definitely NO EMR in his
emergency clinic.He documented the visit
in less than 3 minutes (like I do), signed it, and handed me the top page for
my records.His care was good, his
skills were solid, and his decision-making sound; I would have treated any other
child the same way.

From an economic standpoint, there are two basic approaches
to any service-oriented occupation.The
first is “how much revenue can be generated?”The second is “how can one deliver quality for a reasonable price?” It
is slowly dawning on misguided health economists that the former method is
outrageously expensive.The latter, a
free-market system, is efficient, effective, and helps control cost, but there
are fewer kickbacks available for the cartel of healthcare administrators and
government lackeys that way.The free
market discourages waste and ensures both physicians and patients are mindful
of expenditures, which is supposed to be the goal, right?

85% of medical problems can be handled in a private
clinic or a Direct Primary Care (DPC) setting and 70% of surgeries can be
handled in an outpatient ambulatory surgery center, yet our government
preferentially backs large hospital practices employing physicians and
subsidizing their expensive surgical suites.Health care expenditures rise by the day, yet physician compensation has
been relatively flat over the last few decades.The increasing cost is due to the assorted “add-on fees” of large institutions,
which should affectionately be called “administrator, manager, or IT
surcharges.”This is the reason parents
are charged $39.35
to hold their newborn infant after delivery at the hospital.In my office, it is totally FREE to hold your
own newborn.What a great deal!

Physicians should post prices for general well and
sick visits, basic procedures, and other regular services when feasible,
allowing patients to make better informed decisions.A business that provides value to the
consumer will undoubtedly thrive.The larger
the physician repertoire, the more a consumer reaps the benefits of your
expertise, and the busier the practice becomes.Private specialty care could be provided in this straightforward, streamlined
way as well.Patients are clearly willing to travel outside
the country for good quality medical care at a pre-defined cost, so why not walk
across the street from the large hospital waiting room to an independent physicians’
office?

Free-market medical care encourages healthy competition;
which is bad for the “administrators” and “managers” but very good for patients
and physicians.Domestic medical tourism
could grow as informed consumers are able to search for the right quality at
the right price.My recent brush with
free-market medicine is a beacon of light for how simple medicine used to be. If independent private physicians come out of
the shadows and into the light, embrace price transparency where feasible, then
larger institutions will never be able to compete with us.Now what exactly are we afraid of?

Friday, February 3, 2017

I could never have brought comfort, healing, and
second chances to others without being a physician, but I would never have been
a mother to countless children without being a female.Just as medicine has facets of both art and
science, our femininity is where our courage, fortitude, and unique ability to
restore health and wellness derive their foundation.Possessing the unique innate aptitude to
empathize with others allows us to form enduring intimate relationships with
those for whom we care.Witnessing
first-hand the results our positive contributions can make is absolutely
breathtaking.

Last week, I received a phone call from a mother
with 13 year old twins.We first met
more than 12 years ago when her daughter was terribly sick from urosepsis after
being admitted to our local hospital.She called while my children were taking dance lessons and was
frightened because her son had a fever of 105 degrees and seemed ill.She sounded terrified and needed advice.She has never called me after-hours before.I recommended a fever reducer and gave her
two options:to go to the nearest urgent
care or come to my house after dance lessons were over for me to evaluate him.She asked her son and he wanted to come to my
home.

By the time he walked in my front door, he was
smiling, down to 100.4, and looking pretty stealthy.He hugged me and thanked me for seeing
him.His mom mentioned he was crying at
the thought of going to the hospital or urgent care.Having known him for more than a decade, it
was fairly straightforward to evaluate him, reassure mom it was a virus, and
send him home with instructions for fever management and good hydration.“Wow! You are a doctor and a mom rolled into
one,” he exclaimed.

Last month, a seventeen year old came in for an
appointment unaccompanied.She has been
under my care since she was three.We
share a close relationship that could only exist after many years
together.She is the only child of a
single mother, who has done an excellent job raising this young woman on her
own.Her father left the family years
before due to addiction and mental illness.As I entered the room, she seemed nervous and mentioned feeling
awkward.“My dear, I have known you far too
long for awkwardness, just talk like always,” I reassured.She explained she had been dating someone special
and was interested in obtaining birth control.She sighed and informed me she understood this would only prevent
pregnancy and planned to use condoms for protection from sexually transmitted
diseases.

After a pause, I asked if he was good enough for
her.She smiled and nodded
affirmatively.She reassured me this was
her decision; she had given it much thought and felt ready.She smiled and acknowledged I might not be
ready.I emphasized how proud I was of who
she had become, shared my admiration for her mature approach to making this adult
decision, and applauded the deliberate way she was wisely guarding her future. “Do
not worry about me, I can handle this,” I replied.

Our question and answer session went back and forth and
a birth control method was prescribed.As the visit came to a close, I inquired why her mother had not
accompanied her.She responded “it was
too difficult to handle the reaction of two mothers at the same time.” She preferred
approaching each of us separately.I
asked how she thought our ‘talk’ went, and she agreed it had been easier than
she anticipated.As we walked out to the
front, her mother hugged me knowing what had just transpired.I smiled and asked how she was doing.She took a step back and assessed her
beautiful 17 year old daughter and replied, “Our little girl has certainly grown up and matured into a wonderful
human being.”Indeed.

There is no greater compliment than having someone I
took care of as a child return as a parent with their own little one.Upon reflecting on second generation
patients, a twenty-six year old mother named Sally jumps out immediately.Her mother and mothers’ female partner, Anna,
came in together for that first appointment many years ago when Sally was 10
years old.Sally’s biological mother was
not exactly the mothering type; in contrast, Anna was warm and engaging.

When Sally was 17 years old, her biological mother
died of a drug overdose.Anna took Sally
in, yet had no legal standing to allow for medical decision making.We worked hard to get Sally emancipated; she
went on to finish college and graduate with honors.When she became pregnant a few years later, she
waltzed back in to my office requesting me as the pediatrician for her son.That boy is the spitting image of his mother,
who I recently gave immunizations to at his four year well checkup.

We started discussing the trials and tribulations of
parenting, being that we have children who are the same age.“My mother was dreadful, I could not have
done it without you and Anna; she is my second mom and you are my third” she stated.Tears sprung to my eyes and I replied, “Your
mother loved you in the only way she knew, but you should be so proud of all
you have accomplished, and in what a wonderful mother you have become.”We embraced and tears started running down
her face as well.Her son, Aiden, looked
at us woefully and said, “My shots really hurt, so how come you guys are
crying?”We both burst out laughing.

As physicians, we do our best to set patients up for
successful futures. This instruction can begin when a person is a few days old
and may continue for a lifetime.In
primary care, we observe children grow into adults, finish their educations,
and embark on families of their very own.The single greatest aspect of medicine for me has been to realize the impact
our lasting relationships can have; something that was facilitated by being a
female physician.

February 3rd is National Women's Physicians Day, please join me in celebrating those who blazed our trail. #NWPD #iamblackwell #womendocsinspire